Common Contracts
1 similar Patient Information Form contracts
BURBA DENTAL PARTNERS Advanced Cosmetic DentistryPatient Information Form • September 9th, 2024
___Heart murmur ___Mitral valve prolapses ___Artificial heart valves ___Rheumatic fever ___Cardiovascular disease ___Angina ___Arteriosclerosis ___Congestive heart failure ___Coronary artery disease ___Damaged heart valves ___Heart attack ___Low blood pressure ___High blood pressure ___Congenital heart defects ___Pacemaker ___Rheumatic heart disease ___Abnormal bleeding ___Diabetes Type I/Type II ___Eating disorder ___Joint replacement ___Anemia ___Blood transfusion If yes, date: ______________ ___Hemophilia ___HIV/AIDS ___Arthritis ___Autoimmune disease ___Rheumatoid arthritis ___Systemic lupus erythematosus ___Asthma ___Bronchitis ___Emphysema ___Sinus trouble ___Tuberculosis ___Cancer/Chemo/Radiation ___Chest pain upon exertion ___Chronic pain ___Malnutrition ___Gastrointestinal disease ___G. E Reflux/Heartburn ___Ulcers ___Thyroid problems ___Stroke ___Glaucoma ___Hepatitis, jaundice, liver disease ___Epilepsy ___Fainting spells/seizures ___Neurological disorders ___Sleep disor
